Pink Ribbon Gala Grant Application

Pink Ribbon Gala Grant Application

If you are a Mississippi resident diagnosed with Cancer, and would like to receive assistance, please complete this form and return it to:

The Pink Ribbon Gala Fund

Post Office Box 11188

Jackson, MS 39213

Funding will be given directly to the provider for product or services on behalf of the applicant. Submitting this application does not guarantee funding approval.

Funds for this application are provided by

The Pink Ribbon Gala

Please print clearly and complete BOTH SIDES of this form.

NAME:______________________________________________________________________

ADDRESS:___________________________________________________________________

CITY:___________________________ STATE: ___________ ZIP CODE:________________

PHONE:__________________________ DATE OF BIRTH:____________________________

SECOND PHONE NUMBER, IF POSSIBLE:________________________________________

DATE DIAGNOSED WITH CANCER:_____________________________________________

TOTAL HOUSEHOLD MONTHLY INCOME:_______________________________________

INSURANCE:______________________ MEDICAID and/or MEDICARE? _______________

TYPE OF ASSISTANCE REQUESTED

Please check ALL that apply.

_____Financial Assistance to Help Cover:

_______Medical Bills (Directly Related to Cancer Diagnosis)

_______Cancer Screening

_______Cancer Diagnosis

_______Transportation to medical visits or treatments

_______Utility bill unable to pay due to hardship from cancer expenses

______Prosthesis

______Wig, Hats, Scarves (Head covering)

______Other (Please Specify)____________________________________________________

Please give details about the help you are seeking, so we may have a complete picture of your situation. You may attach an additional sheet, if necessary. Also, please attach supporting documentation of the need, i.e., medical bills, utility bills, etc.

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DOCTOR VERIFICATION STATEMENT:

I verify that the person identified in this application has cancer.

Doctor’s Name:____________________________________ (Please Print)

Have Your Doctor Sign Here:_________________________________ Date:_______________

APPLICATION VERIFICATION STATEMENT:

I swear that the information on this form is true and accurate.

Applicant Signature_________________________________________ Date:_______________

How did you receive this application?_______________________________________________

May we contact you for a statement which may be used in our promotion materials?________

(We will NOT use your name, only your information)